ascertaining resident physicians’ attitudes, perceptions and practices related to cultural...
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Ascertaining Resident Physicians’ Attitudes, Perceptions and Practices
Related to Cultural Competency Training
Ilana S. Mittman, PhD, MS; David A. Mann, MD, PhDCarlessia A. Hussein, DrPH, RN and Mary C. Russell, PhD
Maryland Department of Health and Mental HygieneOffice of Minority Health and Health Disparities
Sixth National Conference on Quality Health
Care for Culturally Diverse Populations
Minneapolis, Minnesota
September 23, 2008
1409 – Resident Physicians’ Attitudes on Cultural Competency
1409 - Resident Physicians’ Attitudes on Cultural Competency
Benefits of Cultural Competence• Greater quality of provider-patient communication• More successful patient education (higher
information recall)• Increased patient health-seeking behavior• Increased patient satisfaction• Increased use of preventive services, and reduced use
of acute care services.• Fewer diagnostic errors• Greater adherence to treatment regimen • Increased trust in the provider
Cooper et al., 2003; The Diversity Research Forum, Summer 2007
1409 - Resident Physicians’ Attitudes on Cultural Competency
Should Cultural Competency Training (CCT) Be Mandated?
• Mandating health professionals’ education in cultural competency (and in general) has been controversial
• Historically, traditional measures of continuing education mandate only attendance not learning and have no measurable performance end point
• Although states have taken steps to mandate CCT, providers’ attitudes about the utility of CCT and issues of enforcement have not been studied yet
• Comparisons between states that have implemented mandatory training to others than have not yet taken place
• The effectiveness of encouragements only - not studied
1409 - Resident Physicians’ Attitudes on Cultural Competency
Cultural Competency Legislation in the U.S.• New Jersey SB 144 – physicians required to receive CCT as pre-requisite for
licensure/re-licensure
• California AB 144 – All continuing medical education courses must contain CC curricula (unless exempt)
• Washington SB 6194 – Each program poised to train healthcare providers in an accredited discipline must include a course in “multicultural health”
• Maryland SB 905, 942 and 883 – Recommending development of cultural competency training; mandating reporting of cultural diversity efforts and cultural competency courses
• New Mexico SB 600 – Enactment of health education cultural competency task force
1409 - Resident Physicians’ Attitudes on Cultural Competency
Legislation Mandating or Strongly Requiring CulturalCompetency Training – U.S.Source: US Dept of Health and Human Services, 2008
Purple – Legislation referred to committee
Navy Blue – Legislation passed, requiring or strongly recommending CCT
Royal Blue – Legislation died in committee or vetoed
WA
CA
NMAZ
CO IL
FL
NJ
NY
OH
GA
MD
1409 - Resident Physicians’ Attitudes on Cultural Competency
Cultural Competency Directives U.S.
• The Joint Commission on Hospital Accreditation (JCOHA)
• The Liaison Committee on Medical Education (LCME)
• The Accreditation Council for Graduate Medical Education (ACMGE)
• Center for Medicare and Medicaid Services (CMS)
1409 - Resident Physicians’ Attitudes on Cultural Competency
The Maryland Case• Maryland ranks second nationally with respect to
active physicians, with 355.0 per 100,000
• Maryland ranks 6th in training of resident physicians
• Maryland is home to prestigious teaching hospitals taking in trainees from around the nation and the world
• Maryland is highly diverse with its population being 41% racial/ethnic minority, and 12.2% being foreign born in 2006
1409 - Resident Physicians’ Attitudes on Cultural Competency
Encouraging Cultural Competency Training: Maryland House Bill 883 (2003)
• 20-801: “encourage courses or seminars that identify and eliminate Health care services disparities of minority populations”
• 20-803: “health care professionals licensing may offer/require staff to take courses on disparities”
1409 - Resident Physicians’ Attitudes on Cultural Competency
First Attempt to Mandate CCTMaryland HB 1295 (2006)
• Proposed requiring schools of medicine to include instruction on cultural competency as a pre-requisite for graduation
• Proposed requiring completion of cultural competency education as a pre-requisite for licensure and re-licensure
• Faced fierce opposition and was amended to require the Department of Health and Mental Hygiene (DHMH) to organize a workgroup of representatives from the Health Occupations Boards and the Office of Minority Health and Health Disparities (MHHD) to discuss specific recommendations
• Amended bill failed and a voluntary partnership between DHMH and the Boards was established
1409 - Resident Physicians’ Attitudes on Cultural Competency
Second Attempt to Mandate CCTMaryland HB 100 (2007)
• Stipulated the convening of a workgroup to require each health occupational board to develop recommendations for requiring individuals licensed by the boards to receive instruction in cultural competency
• Facing fierce opposition the bill was withdrawn in March of 2007
1409 - Resident Physicians’ Attitudes on Cultural Competency
Mandated Reporting of CCT ActivitiesMaryland HB 905 & HB 942 (2008)
Public and private higher education institutions required to report their “cultural diversity” initiates to the legislature, state bodies overseeing higher education and the Office of Minority Health and Health Disparities
1409 - Resident Physicians’ Attitudes on Cultural Competency
A Study to Inform Future Cultural
Competency Legislation Exploratory Questions:
1. Given encouragement only (HB 883) what is the existing degree of cultural competency training in Maryland Hospitals?
2. What are existing attitudes about cultural competency training among Maryland healthcare providers?
3. What is the providers’ knowledge about national guidelines on cultural competency training?
4. Are there differences in the responses based on participant demographics?
1409 - Resident Physicians’ Attitudes on Cultural Competency
Research Design
Develop and disseminate a survey to assess existing practices, perceptions and preferences on CCT
a) Pilot a survey to resident physicians in three community hospitals in Maryland
b) Amend survey based on responses and expand to include additional hospital and health workers in Maryland
c) Collaborate with states who already have mandated CCTd) Make comparisons among disciplines and among states
This presentation focuses on the pilot study only
1409 - Resident Physicians’ Attitudes on Cultural Competency
Target Population
1. Three community-based hospitals serving medically underserved areas - internal medicine residency program
2. One large teaching hospital situated within a diverse low-income population – anesthesiology residency program
1409 - Resident Physicians’ Attitudes on Cultural Competency
The Survey
Administered on-line (SurveyMonkey)
• Participant demographics
• Assessment of existing cultural competency training
• Measure attitudes and perceptions related to cultural competency training (A four-point Likert Scale)
• Measure knowledge of national and state guidelines pertaining to cultural competency
1409 - Resident Physicians’ Attitudes on Cultural Competency
Survey Participants Demographics (n=55)
Asian 16 29.1%White (US born) 18 32.7%White (foreign-born) 9 16.4%Black 3 5.4%Hispanic 3 5.4%American Indian 1 1.8Unknown 5 9.2%
Females 27 50.9%
1409 - Resident Physicians’ Attitudes on Cultural Competency
Survey Participants Demographics (n=55)
Anesthesiology 17 31%Internal Medicine 38 69%
Attending 2 3.6%Chief 2 3.6%Students 2 3.6%R-1 25 45.5%R-2R-3
1419
25.5%18.2%
1409 - Resident Physicians’ Attitudes on Cultural Competency
“Cultural competency training is mandatory in my hospital”
0
2
4
6
8
10
12
A B C D
Hospitals
Yes
No
Unsure
1409 - Resident Physicians’ Attitudes on Cultural Competency
PerceptionsAgree (%)
Disagree (%)
My institution currently has a formal cultural competency training program for house staff
54.5 41.8
Cultural competency is important 94.5 5.6
CCT is too difficult to implement in residency 21.8 78.2
CCT can improve providers’ cultural competency 94.5 5.6
I am satisfied with the existing CCT in my institution 70.9 27.3
There is evidence that CC enhances health outcome 81.8 14.5
CCT increases quality of care 94.5 5.6
Ethnic/racial concordance not important 32.7 63.6
Cultural competency should be acquired at home and can not be taught
5.4 92.7
On-line training is better for my schedule 52.7 43.6
1409 - Resident Physicians’ Attitudes on Cultural Competency
Perceptions by Specialty Type(statistically significant comparisons)
Item Median (Mean)
(Since the distribution is not normal, and the variables are ordinal we have conducted the Mann-Whitney Test. Both medians and means are displayed because medians of the groups overlap. See next graph for illustration)
AnesthesiaN=17
Internal MedicineN= 38
P value(Mann-Whitney Test)
Cultural competency is important 3 (2.8) 4 (3.5) 0.001
CCT too difficult to implement in residency 2 (2.3) 2 (1.9) 0.017
CCT can improve providers’ cultural competency 3 (2.8) 3 (3.3) 0.003
Cultural competency should be acquired at home and cannot be taught
2 (1.9) 2 (1.6) 0.036
1409 - Resident Physicians’ Attitudes on Cultural Competency
Perceptions by Gender(statistically significant comparisons)
Item Median (Mean)
(Since the distribution is not normal, and the variables are ordinal we have conducted the Mann-Whitney Test. Both medians and means are displayed because medians of the groups overlap. See next graph for illustration)
FemaleN=27
MaleN= 26
P value(Mann-Whitney Test)
Cultural competency is important 4 (3.5) 3 (3.0) 0.007
CCT too difficult to implement in residency 2 (1.8) 2 (2.3) 0.01
There is evidenced that enhanced CCT improves health outcome
3.0 (3.2) 3.0 (2.7) 0.05
1409 - Resident Physicians’ Attitudes on Cultural Competency
Example of Distribution of Responses by Specialty to the Statement:
“Cultural competency is important in healthcare delivery”
2
01
0
12
20
2
18
0
2
4
6
8
10
12
14
16
18
20
Number of Responses
StronglyDisagree
Disagree Agree StronglyAgree
Anesthesia
Internal Medicine
1409 - Resident Physicians’ Attitudes on Cultural Competency
Awareness of National Guidelines: Responses to the Statement:
“Do the following bodies either require or recommend cultural competency preparedness of medical staff?”
0
5
10
15
20
25
30
35
40
Number
AAMC LCME JCAHO AAFP HRSA
Accreditation Bodies
Yes
No
Not Sure
1409 - Resident Physicians’ Attitudes on Cultural Competency
Reported Training StylesTraining Style Number %
Web-based 16 29.1
Didactic 13 23.6
Workshops/
seminars
14 25.4
Community Immersion
10 18.2
Grand rounds 10 18.2
1409 - Resident Physicians’ Attitudes on Cultural Competency
Results Highlights (1)
• The majority of respondents agreed with the importance and utility of CCT
• The majority of respondents disagreed that CCT is too difficult to teach in residency
• There is confusion about requirements related to CCT even within one’s institution
• The vast majority of respondents were unsure about licensing and accreditation boards’ recommendations related to CCT
1409 - Resident Physicians’ Attitudes on Cultural Competency
Results Highlights (2)• There were no statistically significant differences in
perceptions related to CCT between minorities and non-minorities
• There were significant differences by specialty type in the strength of agreement that CCT is important (internal medicine agreeing more strongly)
• There were significant differences by gender in the strength of agreement that CCT is important (women agreeing more strongly)
• Some findings of this study (regarding interest and level of formal training) are supported by earlier studies (Park et al., 2006)
1409 - Resident Physicians’ Attitudes on Cultural Competency
Conclusions and Recommendations• Overall, in our study, physicians in residency regardless of
race and ethnicity recognize the importance of CCT and do not view the training as a hard task
• Residents with more limited patient contact may be less likely to value CCT
• Teaching faculty and residency directors must communicate CCT recommendations and guidelines put forth by the institution and by external accreditation agencies
• CCT is essential in residency, often the last point of supervised medical training
1409 - Resident Physicians’ Attitudes on Cultural Competency
Study Limitations
• Convenience sampling – external validity• Small sample size• Volunteer participation may introduce a
selection bias (in favor of CCT)• Comparisons between specialties should be
made with physicians within the same hospital
1409 - Resident Physicians’ Attitudes on Cultural Competency
Future Studies
• Survey to be disseminated to the entire healthcare workforce in Maryland hospitals comparing specialties (60 hospitals in MD)
• Perceptions related to mandated training for graduation; licensing and re-licensing to be ascertained
• Comparisons to be made with states that have implemented mandatory training
1409 - Resident Physicians’ Attitudes on Cultural Competency
Contact Information
Minority Health and Health DisparitiesMaryland Department of Health and Mental Hygiene
201 West Preston Street, Room 500Baltimore, MD 21201Phone: 410-767-7117
Fax: 410-333-5100Email: [email protected]
Website: www.mdhealthdisparities.org